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City of Orono <br /> Building Permit Application for Maintenance / Replacement/ Remodel — Residential ONLY <br /> (i.e. windows, doors, siding, re-roof, etc. — NO STRUCTURAL EXPANSION) S� �( <br /> �OAt Mailing Address: Permit number: p7�I v !2 <br /> 17 <br /> O PO Box 66 <br /> Crystal Bay, MN 55323-00. Date received: <br /> A a <br /> Street Address: (���� Received by: <br /> ti� G� 2750 Kelley Parkway 9' Plan review fee: <br /> t Orono, MN 55356 <br /> �kESHO a3 g•30 <br /> Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: 4105 Highwood Rd. Mound MN 55364 <br /> Job Site Address: <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑Yes ❑x No <br /> If yes,a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will be <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFORMATION: Jason from Pro Storm Exteriors Will provide License number for siding <br /> Name: Jason Berg (For Siding Only)Jason Peterson for the Trim work <br /> State License# BC#634454 exp 3/31/19 Expiration Date: 3/31/19 <br /> Lead Certification Number: Lead# NAT-117141-2 exp 10/10/21 Expiration Date: 10/10/21 <br /> (for work on homes that were constructed prior to 1978 <br /> Phone: (cell) 612-269-6506 (office) <br /> Mailing Address: 4105 Highwood Rd Cit : Mound ZIP: 55364 <br /> Contact Person: Jason Peterson Applicant is: Contractor Homeowner (Circle One) <br /> Email and/or Fax: jasgooday@gmail.com For Siding <br /> Siding- Jason Berg -jason@stormproexteriors.com, 612-810-9781 <br /> PROPERTY OWNER INFORMATION: <br /> Name: Jason&Anelise Peterson <br /> Phone(day): 612-269-6506 <br /> Address: 4105 Highwood Rd City: Mound ZIP: 55364 <br /> Email and/or Fax: jasgooday@gmail.com <br /> PROJECT INFORMATION: Overall project description: <br /> Type of Project: Any earth movement may also require <br /> MCWD review&permits: <br /> ® Door(s) Interior ElRemodel CIFire Damage <br /> El Re-roof,asphalt 11 Repair El Storm Damage Minnehaha Creek Watershed District(MCWD) <br /> 15320 Minnetonka Blvd <br /> ❑ Re-roof,cedar ❑ Restoration ❑Water Damage Minnetonka,MN 55345 <br /> Phone: 952-471-0590 <br /> ❑ Re-roof,other specify) ❑x Siding ❑ Other:(specify) Fax: 952-471-0682 <br /> Trim Work Window(s) www.minnehahacreek.orq <br /> Estimated Construction Valuation of Project(excluding land) $ $12,000 <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they are <br /> solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative but to <br /> reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data. <br /> Confidential data is information which generally cannot be given to either the public or the subject of the data. Our purpose and <br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If <br /> you refuse to supply the information,therenapplication may not be issued. <br /> Applicant's Signature: "�/" 42,9)t- Date: 2-8-2018 <br /> Owner's Signature: /I "�� �� Date: 2/8/2018 <br /> Last Updated:January 2016 <br />